Not the Only Canary in the COVID-19 Coal Mine: A nurse’s story of post-traumatic stress disorder

Names have been changed to protect the author's privacy

Well into the 20th century, coal miners brought canaries into coal mines as an early-warning signal for danger from toxic gases.

COVID-19 has had a significant detrimental impact on the health of nurses and midwives. I’m telling my story as part of making sense of what has happened to me and the significant health impact working as a frontline nurse in the COVID-19 pandemic has had on me. I am not the only canary in the COVID-19 coal mine of this pandemic.
 

I am curious as to why I am one of the few nurses singing about the COVID-19 impact our health. This is not unusual when it comes to mental health issues. Those affected often do not go public about their mental health issues. Some do not even admit it to themselves. Stigma, shame and fear are some of the reasons nurses and midwives remain silent about what COVID-19 has done to their health.

Stigma, I suspect, is only one reason nurses and midwives remain silent. Stigma is a stain or blemish as perceived by others and by the one affected. A blemish that — although based on ignorance — leads to negative attitudes and concerns about performance capacities and potential impact on personal and career progression or opportunities. These — usually unfounded — fears exist within us even in relation to those closest to us such as family. The fear is then multiplied when it comes to our work environment where reputation and competence are critical.

Those not working in health may be surprised that even some health managers and Human Resource departments still struggle to manage this area well enough. Therefore, many staff lack the confidence to approach their employer when they need to and should. 

Concerns about the effectiveness of Employee Assistance Programs (EAP) have been discussed in the literature for some time. So much, in fact, that the Productivity Commission Inquiry Report 2020 recommended that minimum standards be developed and for the evaluation of the efficacy of these programs.  
But that’s a scholarly article. This is a personal account — a brief description of one nurse’s journey into a diagnosis of Post-Traumatic Stress Disorder, secondary to trauma associated with working in up to 40 Residential Aged Care Facilities (RACF) that had COVID-19 outbreaks from March to mid-November 2020. During this period approximately 176 residents died because of COVID-19 in circumstances that I could never have imagined. I am back at work in December 2021 and the Omicron COVID-19 variant is impacting us and the residents I care for.
 

I am 63 and have been working in health care since I was 18. I have worked as an orderly, nurses’ aid, Registered Nurse, ANUM, NUM, Operations Manager and Director. For the last nine years I have worked as a Clinical Nurse Consultant for a public health community-based service. The objective being to provide for RACF clients an alternative to having to go to an emergency department or possibly be admitted to hospital. This program offers an alternative to potentially longer inpatient stays. 

If you had asked me at the start of 2020 that I might be diagnosed with PTSD, I would have thought you were joking. I have never experienced the workload, stress, number of deaths and trauma in my long career.

Here are some factors that I believe led to the development of PTSD. 

Inside an RACF during an outbreak

For those who have not worked on the COVID-19 frontline and were not exposed to what it was like working within RACF’s during an outbreak, let me try and offer you a Readers Digest of some of the issues we encountered and found traumatic over an extended period — many continue to be experienced today.

The following things happen when a RACF has an outbreak.

• Most if not, all visiting services that normally support the residents stop attending. Including GPs, Locums, Physio & Speech therapists, Dental, Wound Consultants, Pathology services, Leisure therapists, etc.
• In one recent example cleaners stopped going and the contractor cancelled the contract.
• Some staff are unable to attend as they are quarantined as close contacts.
• Other staff don’t attend as they are frightened of contracting the virus themselves and or their families don’t want them to attend.
• Air-conditioning units can be turned off for fear of increasing transmission within a facility. 
• All leisure activities cease.
• All communal activities cease, including dining.
• All visitation from family and friends ceases.
• Residents who are dependent on visitors to help them eat and drink or to ease behavioural issues lose access to this support.
• Water jugs are replaced with water bottles and Styrofoam cups. Residents found these often difficult to use and increased the risk of dehydration.
• Residents were asked to remain in their rooms 24 hours a day, windows & doors closed.
• Residents often lost access to outdoor areas and sunshine.
• Staff caring for residents were replaced by agency staff not familiar with the residents, the facility or each other. As a result, no matter how hard they tried — and they did do their best — they could not provide the same standard of care as provided by the regular staff.
• The replacement staff had to work in full PPE. This meant residents — many with cognitive impairment — found it hard to recognise and or hear the staff due to masks and face shields. They lost the benefit of the simple joy of touch due to the need for staff to wear gloves.

All of this happened from day one and often lasted for weeks to months. In some instances, visitation rights stopped or were severely limited for more than 10 months. 

Death by isolation

As you might imagine, if you did this to any population — let alone a frail elderly population with multiple pre-existing comorbidities — those affected quickly became depressed. Residents were isolated in their rooms with little social interaction except for fleeting visits from staff, many of whom they didn’t know or recognise due to PPE. Many residents simply went to bed and stayed there. As a result, they declined further in mood, functionally, cognitively, behaviourally and ate and drank less. My residents lost weight, became malnourished and dehydrated. Many of these residents were not COVID-19 positive and died from lack of care. Their deaths were not recorded as being due to COVID-19. 

Their death is because of ‘Sis’ — what we called COVID Isolation Syndrome, or CIS. CIS is still not adequately recognised and certainly not compensated for. 

Some of the things that happened after the initial stages of the pandemic varied but some stayed the same.

Our team’s role

When an outbreak was detected at a facility, the Department of Human Services were notified. They contacted my health service for support. We immediately attended to undertake a situational analysis and attempted to support the facility managers, staff, and residents.

On day one, it was rare for any of the COVID-19 positive residents to be seriously unwell. But some residents were. The difference was that neither GPs nor Locum doctors would attend. As a result, only our service was available to attend. We assessed the residents and managed medical issues and provided care and support.

As you might imagine, this was a monumental task. Our initial team of six Nurse Consultants, a Nurse Practitioner, a Registrar and a part time Geriatrician quickly expanded to a team of approximately 40. This included runners, additional registered nurses, clerical and medical support. Medical support went from being available only Monday to Friday day duty to AM and PM shifts seven days a week at the peak. 

Typically, COVID-19 positive residents declined progressively over a seven-day period and then succumbed to the illness between day seven and ten. Those that survived beyond day 12 left us with a growing degree of confidence that they would recover.  

In too many cases we were unable to offer the most seriously affected much more than comfort or Palliative Care. Over 10 months 176 residents died in facilities we supported through outbreaks. 

Sadly, these residents died isolated from family. Being cared for by staff that were often not known to them. This occurred in the absence of even the comfort of touch of another’s hand because of the need for us to work in PPE.

Witnessing the grief of distant families

For family, it was just as hard for the same reasons. 

Family would receive calls advising them that their mother or father was COVID-19 positive, then daily calls advising them of either a gradual or sudden decline. They usually hadn't seen them for months. Then, over the phone, they are told the one they love has either already died or is believed to be terminal.

I made many of those calls. 

In some instances, families didn’t want to come in for fear of the infection. On other occasions the residents didn’t want family to come for the same reason. On other occasions, I had to advocate for the next of kin to be allowed to attend because their parent or partner was dying.

The most memorable of these conversations was with the daughter of a man I will call Jack. I found Jack one evening when I went to work in a RACF. I was told by staff they were concerned about him. When I eyeballed Jack from the door of his room I knew he was sick. He appeared very distressed, and I immediately became concerned that Jack was terminal. The relieving staff were unsure of his Advanced Care Directive (ACD) status. On this occasion I had the benefit of having a Geriatrician with me.

While I repositioned Jack and applied O2, my colleague contacted his daughter. The outcome of reviewing the ACD and discussion with the daughter was that Jack was not for transfer to hospital and that his goals of care was to focus on comfort.

As a result, I then gave Jack 2.5mg of both morphine and midazolam. The O2, repositioning and SC medication quickly settled Jack to the point that we were able to have a conversation in brief sentences within the limitations of his respiratory function. I became aware that his wife had died some time ago. He was close to his daughter and grandchildren. Because visitors were not allowed — even before his facility had the outbreak — Jack had not seen his daughter in months.

I got his daughter on my mobile and had a brief chat about how we had been able to get Jack more comfortable. I then held the phone for Jack in one hand, and the mask away from his face enough so he could both hear and talk to his daughter. 

I remember the conversation, trying to hide my tears from Jack. I cried through much of it. It will remain a private conversation except for one component. 

Jack’s daughter said near the end, “I love you Daddy."

Jack replied, “You haven’t called me Daddy in a long time.”

“I know Daddy. I’m sorry."

This was only one of many calls I made to family of those dying in my care. When I returned the next morning, I was advised Jack died comfortably that night.

Frustrations and anxieties over workplace policies

I believe my frustration with workplace policies and practices contributed to the development of PTSD. An example is that I felt I needed to instigate an Intelligent Disobedience clause from my employment contract. 

Early in 2020, we were advised that the policy regarding PPE when testing a suspected COVID resident had changed. We were now only to wear a small plastic apron and standard surgical mask, not full PPE. 

At that time there had been media reports about concern over adequate access to PPE. In the absence of open and frank discussions, my personal belief was that this policy was more about supply than science.

I said I could not comply with this policy directive and intended to continue to wear full PPE and would encourage my colleagues to do the same. Not to do so put us at risk — myself, my next patient, my colleagues, the organisation, and my family. As a result, we hid PPE to ensure adequate supply and continued to wear full PPE.

About 8 weeks later the policy was quietly changed.

We were provided with N95 masks early on, though we did not initially have access to mask fitting. RACF staff were not. I raised this as a matter of concern as I worried that we would lose relieving staff to COVID isolation if they became infected. This fear became a reality. We did in fact lose even more facility staff to quarantine before they were eventually provided with N95 masks. 

I was eventually tested for mask fitting two weeks after we closed our last outbreak facility in mid-November 2020. I was advised that none of the masks I had available to me during the previous 10 months had been a safe fit. Bit late.

On two occasions I also came across facilities where fire doors were blocked by furniture as a means of ensuring staff and or wandering residents didn't move from what was considered an infected area to a clean one.

Uncertainty about executing decisions we might not support

Patients were moved out of facilities after an outbreak occurred, but these were not our decisions unless it was purely on medical needs. Our concern related then and now to being unable to predict when, why or who would be decanted from an outbreak facility. Over 2020, whole facilities were closed, the positive patients moved out or the negative patients, or some or all or wandering residents were moved. 

On two occasions, I witnessed the separation of married couples who both had dementia. They were separated for reasons they did not understand or remember — but they did know that their partner was not with them and would beg me to help. Our concern and frustration were and is that we never new who, why or when residents would be decanted.

More recently we have observed, in our opinion, that patients became infected because patients are not decanted in a logical or in a timely fashion.

Taking it home

At home, we carried our concerns with us. Worried that we could take the virus with us into the sanctity of our homes and family. A colleague from an RACF did just that. She and her two young children developed mild illness but her husband ended up in ICU intubated. He survived but is still recovering a year later.

My son is autistic. He has low support needs,  and I am very proud of him. Like me, COVID-19 took its toll on him. He is an insulin-dependent diabetic, as am I. He was concerned I would bring the virus home or contract it myself. 

He would say, “Dad you are 63, insulin-dependent and have idiopathic cirrhosis of the liver. You are at high risk of being very sick if you get COVID-19.” 

I'd returned fire with, “I know, but I'm far more likely to contract it at a supermarket, on the way home than at work.”

Developing PTSD

My service worked in Covid outbreak facilities every day for 10 months until the end of the third wave. The detail above is only a glimpse of the kind of issues that contributed to the kind of sustained stress that my team worked under.

There are many factors that led to me developing PTSD. Some were situational, others related to inadequate communication or recognition of what we were dealing with. Some were the result of policy and resources that lagged the rapid pace of the pandemic.

Like most nurses and midwives, when we are in the ‘eye of the storm’, we keep going. A job needs to be done and we do it. We forget to pause and reflect on the negative impact our work is having on our health and wellbeing. I wish I had stopped sooner and acknowledged that I needed a break.

My employer did offer support, but I think that we all underestimated the toll that this experience would take.

Recognising the symptoms

I have learned that nurses are not particularly good at recognising and responding to signs of emotional or mental exhaustion in their colleagues. I was witnessed crying on two occasions while assisting with media reporting and again during three zoom-based psychologist-led group debriefing sessions. Yet I wasn’t approached privately to see if I was OK.

While in the thick of the COVID-19 aged-care impact, I thought I was OK. I was doing my job. When things slowed down, I began to struggle. I experienced poor sleep, increasing agitation, anger and frustration. I lost interest in life. I questioned everything that I did or didn't do and experienced unpredictable and uncontrollable tearfulness. Progressively, I noticed physical symptoms, signs I wasn’t well. These included frequent hypoglycaemic episodes, intermittent tremor, and loss of appetite. I began to have reoccurring dreams, mostly of that call with Jack.

The crisis came when I weighed myself and realised I had lost 16kg in 5 weeks.

I was unsure what to do regarding work but knew I needed support. I informed my manager what was going on and that I was seeing my GP, a psychiatrist, and a psychologist. I then went on four weeks’ annual leave and returned to work on a gradual basis over an eight-week period until I was able to resume full duties.

During this time, I reached out to many colleagues. I was concerned that there was a hidden tsunami of stress, anxiety, depression, and PTSD impacting nurses.

Awareness of your health and wellbeing is the first step towards seeking support and getting help.

This was illustrated to me because of a conversation and email from a colleague who had resigned from the service. I rang to check on them, to tell them my situation and let them know that I was concerned others may be feeling the same. The person typically empathised, said they were OK and offered me support.

The next day my wife found me sitting on the couch in tears. She approached me concerned. I reassured her I was OK. In fact, I was weirdly pleased as my colleague had just sent me a text along the lines of: Thanks for the call and the honestly, I lied, I'm not OK!  I am seeing my GP and will see a psychologist. I’m taking a break from work.
 

This is part of the reason I’m writing my story. If you are a nurse, midwife, student or other worker who has been impacted by COVID-19, reach out for support. If my story resonates with you. If it gives you a voice, I hope you now have permission to speak out and seek help.

My call-to-action is: we must all do more to support those who are struggling. If you notice the person in a meeting next to you doesn’t seem themselves, or the clinician you are working with doesn’t seem OK, pause to take them aside, check in and offer support.

Nurse & Midwife Support is the national 24/7 support service for nurses, midwives and students and anyone concerned about our welfare: 1800 667 877.

I acknowledge the many nurses and health workers who have died from COVID-19 in the course of their work. No doubt they would wish that every person suffering has the support they need.

I honour Gillian Dempsey, the first Victorian nurse to die from COVID-19. I hope her loved ones and colleagues have the support they need.

Like me, you may still be working on the COVID-19 frontline as this virus continues to challenge us.

I urge you to look after yourself and your colleagues and seek support when you need it.

Navigating your response to the pandemic can be stressful. If you’d like to chat about it, reach out to Nurse & Midwife Support — free, confidential, 24/7. Give us a call on 1800 667 877 or by email.